SERVICE SURVEYS, LIFESTYLE AND CHRONIC DISEASES BELGIAN NATIONAL REPORT ON DRUGS 2014 NEW DEVELOPMENT AND TRENDS

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1 SERVICE SURVEYS, LIFESTYLE AND CHRONIC DISEASES BELGIAN NATIONAL REPORT ON DRUGS 2014 NEW DEVELOPMENT AND TRENDS

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3 BELGIAN NATIONAL REPORT ON DRUGS 2014 (DATA 2013) NEW DEVELOPMENT AND TRENDS

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5 Scientific Institute Public Health (WIV-ISP) Operational Directorate Public Health and Surveillance Service Surveys, Lifestyle and Chronic Diseases Programme Drugs Julliette Wytsmanstreet Brussels Belgium Public Health & Surveillance November 2014 Brussels, Belgium EDITORS Lies Gremeaux Els Plettinckx AUTHORS Belgian Monitoring Center for Drugs and Drugs Addiction (BMCDDA) Programme Drugs Jérôme Antoine Peter Blanckaert Karin De Ridder Lies Gremeaux Els Plettinckx EXTERNAL EXPERTS Lucia Casero EUROTOX asbl (socio-epidemiological observatory for alcohol and drugs in the Federation Wallonia-Brussels) Fred Laudens VAD (Association for alcohol and other drug problems) Freya Vander Laenen Department of Penal law and Criminology, Institute for International Research on Criminal Policy (IRCP), Ghent University

6 Contact Website: drugs.wiv-isp.be This document is available on the website of the Programme Drugs (drugs.wiv-isp.be) and the website of the Scientific Institute Public Health ( Please use the following citation: Plettinckx, E., Antoine, J., Blanckaert, P., De Ridder, K., Vander Laenen, F., Laudens, F., Casero, L. & Gremeaux, L. (2014). Belgian National Report on drugs 2014, New Developments and Trends. WIV- ISP, Brussels. Lay-out Nathalie da Costa Maya, CDCS ngo WIV-ISP, Brussels 2015 Responsible publisher: Dr. Johan Peeters Depotnumber: D/2014/2505/66

7 CHAPTER 5. DRUG-RELATED TREATMENT: TREATMENT DEMAND AND TREATMENT AVAILABILITY Antoine J. Since 2011, the number of treatment demands for cannabis as primary drug shows a steep increase and a decrease for opiates. In 2013, patients most commonly reported the use of cannabis (33.5%) for entering treatment. A first pilot project on assisted treatment with diacetylmorphine in Belgium recommends to extent diacetylmorphine treatment as a second-line treatment for patients who continue to use street heroin despite treatment with methadone. 1. INTRODUCTION Due to the sixth state reform, the Communities are to become more competent in political and policy initiatives, which will radically change the drug treatment sector in Belgium. This evolution in the institutional status of the country leads currently to a transitory situation (see chapter 1). This chapter comments on the most recent situation on drug-related treatment in Belgium. First, the common declaration on drug policy is screened regarding treatment information (section 1.1) and organizations working on drug-related treatment field (section 1.2) are presented. Key figures, based on treatment demand indicator data from 2013 (section 1.3) and a description on the different treatment modalities (section 1.4) are described. Trends on the number of treatment demands and on people following a substitution treatment are presented (section 2). Finally, a review of the most recent developments in the field of drug-related treatment (section 3) concludes this chapter. 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY 77

8 2. DRUG-RELATED TREATMENT IN BELGIUM 2.1. POLICIES AND COORDINATION 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY 78 An efficient drug policy requires a global and integrated approach. In 2010, the representatives of all governments in Belgium (Federal Government, Walloon region, Flemish region, French Community, Brussels-Capital Region, Germanspeaking Community, the French-speaking authorities in the Brussels-Capital Region and the Common authorities in the Brussels-Capital Region) have signed a common declaration entitled A global and integrated drug policy in Belgium. The main treatment-related objectives mentioned in this document are: 1) promoting a global and collaborative strategy for help, starting from an approach on health and integrating other dimensions (such as wellbeing and social integration), 2) providing cure/treatment as well as care and support, 3) providing a large choice of facilities, specifically dedicated to drug users or global health care and services related to well-being, 4) creating a balanced geographic spread of the settings based on the evaluation of needs, 5) guaranteeing the availability of various treatment programmes, including drug-free treatment, withdrawal treatment, substitution treatment, harm reduction initiatives, reintegration and aftercare, 6) promoting integrative treatment with a focus on dual diagnosis, employment, housing, and psychosocial problems, 7) developing a collaborative care/treatment network offering general and specific approaches, 8) training of new health care workers in order to ward off waiting lists, 9) promoting case management focused on individualized support in specific groups. In the light of this common declaration, a general drug policy cell was created in which 17 representatives of the Federal Government and 18 representatives of the Regional Governments, a national drug coordinator and a vice-coordinator participate. Its main purpose is to formulate well-elaborated recommendations in order to synchronize drug policies ORGANIZATION AND AVAILABILITY OF DRUG TREATMENT In Belgium, there is a large variety of treatment or help facilities for persons with drug-related disorders. The main objective of these services for drug-users is the promotion of quality of life in terms of global health (physical and psychological) and in terms of welfare and respect of the autonomy of the client.

9 The primary care network is the first, low-threshold step for organised help. These facilities are the best to detect a substance related problem, to evaluate and eventually to redirect if more specialised help is needed. This network is composed with general practitioners, centres for general welfare, services of domiciliary care, youth advice centres and public centre for social welfare. Next to primary care, ambulatory or residential specialised treatment are also available and will be described in detail in the following sections. The federal state is responsible for health care insurance and for defining the basic principles for inpatient treatment (hospitals). In the health policy sector, the Communities have responsibilities in administrating in- and outpatient care as well as in the field of health education and preventive health care. This implies that the Communities are responsible for laying down rules for institutions that fall under their jurisdiction and for implementing federal regulations. On a regional level, centres for mental health in the Flemish region are coordinated by the Flemish Agency for Care and Health. For their part, the Walloon region (General Directorate Social Action and Health) subsidized specialised addiction centres respecting the recommendations of the addiction decree (B.S./M.B ). In Brussels, the French Community Commission funds specific projects on treatment, prevention, support and (social) reintegration. Since the 80 s, conventions are concluded between specialised centres for the treatment of addictions and the National Institute for Health and Disability Insurance (NIHDI) in order to stimulate new initiatives in this field. In 2013, 29 conventions were signed with ambulant or residential centres working on specific medical and psychosocial treatment. These centres represent a large (but not exhaustive) and diversified part of the treatment offer for drug users in Belgium. Conventions with revalidation centres for drug users financed by the NIHDI will be transferred to the Communities in the near future. 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY Outpatient network An overview of the available outpatient treatment facilities is presented in Table 5.1 and 5.2, describing a definition of the different types of centres and their importance in terms of number of illicit drug treated patients respectively. General practitioners may play an important role in the treatment of drug users, however these are not mentioned in the tables because of the current lack of this information. 79

10 Table 5.1 Network of outpatient treatment facilities (total number of units) 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY 80 Type of centre Total number National definition Specialised drug treatment centres Low-threshold agencies 34 Day care centres are specialised centres that reach a large group of people with drug-related problems (ranging from new users to persons with severe substance-related disorders) and their relatives or friends. Psychosocial, administrative, judicial support is offered on an individual basis or as part of group therapy. During these programmes, total abstinence is not mandatory, however clients cannot be under the influence during the activities. Substitution treatment (e.g. methadone or buprenorphine) is also available in these centres. The emphasis is put on the guiding process during the transition towards a better structured life. Day care centres are present in the Flemish region (6), in the Brussels-Capital region (9) and in the Walloon region (19). 9 Medical and Social Care Centres (MSCC) are low-threshold agencies that offer social, psychological and health care services to persons with a substance-related disorder. Their main objective is to get into contact with people normally excluded from the standard treatment facilities. A large part of their daily work comprises medical and social care, harm-reduction and substitution treatment. Some of them also offer a needle exchange programme. In the Flemish region, there are 5 centres (known as Medisch en Sociaal Opvangcentrum, MSOC)). In the Walloon and Brussels- Capital regions, there are 3 and 1 centre(s) respectively (known as Maison d Accueil Socio-Sanitaire, MASS). Mental health care 31 Some mental health centres are also specialised in the treatment of substance-related disorders with the reduction of consumption or even total abstinence as the ultimate goal of their services. A variety of treatments is available within these centres: from an individual approach to group, relational and family therapy. Clients that present more complex problems such as dual diagnosis of substance use are admitted to an adapted, specific treatment offer. In the Flemish region there are 20 centres (known as Centra voor Geestelijke Gezondheidszorg, CGG). In the Walloon and Brussels-Capital region there are respectively 8 and 3 centres specialised in addiction (known as Service de Santé Mentale, SSM). Source: BTDIR, 2014 Table 5.2 Total outpatient treatment provision for illicit drug treatment demand (number of clients) in 2013 Type of centre Total number of clients entering treatment Coverage of monitored treatment facilities Specialised drug treatment centres 2, centres / 34 in total Low-threshold agencies 1,795 9 centres / 9 in total Mental health care 1, centres / 31 in total Source: BTDIR, 2014

11 Inpatient network Inpatient treatment structures are mostly represented by hospitals. Besides these general structures, there are also specialised centres for drug users in crisis situations (crisis intervention centres) or in a more stabilized phase (longterm residential centres, including therapeutic communities). An overview of the available inpatient treatment facilities (Table 5.3) and provision (Table 5.4) is presented below. Table 5.3 Network of inpatient treatment facilities (total number of units) Type of centre Hospital-based residential drug treatment Crisis intervention centre Therapeutic communities or other long-term residential centres Source: BTDIR, 2014 Total number of centres National definition 120 Among all hospitals in Belgium, psychiatric hospitals as well as psychiatric units in general hospitals have a limited capacity to treat patients with substance use. In some hospitals, there s a special programme for drug users. The range of care options can be very extended in hospitals. In order to evaluate the number of hospitals where drug users can be treated, the number of hospitals with specific psychiatric beds were considered (Classified as beds A, T, K). There are 67 hospitals in the Flemish region, 16 in the Brussels-Capital region and 37 in the Walloon region. Nevertheless, not all psychiatric beds are used to treat substance users. 8 Crisis intervention centres are short-term residential treatment centres that guarantee the unconditional and rapid support in case of a crisis situation. They promote a physical detoxification and motivate for further abstinence or guide patients towards the best fitted treatment programme. There are 5 crisis centres in the Flemish region, 1 in the Brussels-Capital region and 2 in the Walloon region. 15 Therapeutic communities were the first treatment initiatives for drug users in Belgium. Other long-term residential centres are also presented here. They are drug-free environments with a strong focus on self-help and peer support. A hierarchical community structure and group therapy sessions are the key lead to detox and to reintegrate patients into the society. There are 8 therapeutic communities in Belgium: 5 in the Flemish region and 3 in the Walloon region. A recent European publication gives a more detailed picture of therapeutic communities in Belgium and more generally in Europe (Vanderplasschen et al., 2014). 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY 81 Table 5.4 Total inpatient treatment provision for illicit drug treatment demand (number of clients) in 2013 Type of centre Total number of clients Coverage of monitored treatment facilities Hospital-based residential drug treatment 2, hospitals / 120 in total Crisis intervention centre centres / 8 in total Therapeutic communities centres /15 in total Source: BTDIR, 2014

12 2.3. TREATMENT DEMAND DATA The Treatment Demand Indicator (TDI) registration in Belgium was officially approved by the Inter-ministerial conference on Public Health in 2006 (B.S./M.B ). Consequently, a national TDI protocol was adopted in 2010 based on the EMCDDA Protocol version 2.0. On this basis, the TDI registration was launched at national level in specialised centres in Prisons and general practitioners are currently not part of the registration. This system registers both patients entering treatment for illegal drugs as well as alcohol as a primary substance. A new European protocol was adopted in 2012 and had to be implemented in EU member states. At national level, a new protocol was adopted in September 2013 and will be the basis for the TDI registration from 2015 onwards. 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY The specialised residential and ambulatory centres are using an online application since 2011 to encode their clients or are sending their data through a repository module. In 2013, around 100 specialised centres participated in this TDI registration. In 2013, a total of 9,192 drug users entered treatment in the centres that report data. Around 73% and 45% of the specialised out- and inpatient centres in Belgium are reporting data. More or less 2 patients out of 3 (64.0%) were registered in outpatient centres and 36.0% in inpatient centres. In all types of centres, patients most commonly reported the use of cannabis (33.5%) for entering treatment (see Figure 5.1), next to opiates (30.7%), cocaine (15.6%), stimulants other than cocaine (11.3%) and misuse of hypnotics and sedatives (6.1%). Characteristics of patients and addiction profile of patients entering treatment for the different substances are described in Table

13 Figure 5.1 Proportion (%) of treatment demands by primary drug in Opiates 33.5 Cocaine Stimulants other than cocaine Hypnotics Cannabis Other substances Source: BTDIR, 2014 Table 5.5 Characteristics of patients entering treatment in 2013 by type of primary drug Characteristics of patients Type of primary drug mentioned for entering treatment Opiates Cocaine Stimulants Hypnotics Cannabis Women (%) Mean age (years) Ever injected (%) Daily users (%) Use of only one substance (%) First time in treatment (%) Mean age at time of first use (years) Source: BTDIR, 2014 Remarkably, the majority of the group of persons in treatment for hypnotics are women. On the opposite, women are the least represented in the group of cannabis users in treatment. The mean age of patients in treatment is higher for people in treatment for hypnotics and opiates than in the group in treatment for cannabis and stimulants. The proportion of people that ever injected a substance is the highest in the group of people in treatment for opiates. Patients in treatment for hypnotics or cannabis are using less other substances (alcohol included). The registration shows that most patients using opiates already went into treatment in the past. The mean age of first time use is the lowest for cannabis users. 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY 83

14 2.4. TREATMENT MODALITIES 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY Opioid substitution treatment In Belgium, methadone and buprenorphine are the two substances authorized for opioid substitution treatment (OST). The provision is organised by both specialised centres and general practitioners. Since April 2009, prescriptions for methadone and buprenorphine are registered in the Pharmanet-system of the NIHDI. The objective of this registration is to avoid multiple prescriptions and allow warnings among involved practitioners as requested by the Royal Decree of March 19th 2004 (B.S./M.B ). This database contains information from public pharmacies, hospital pharmacies and specialised centres. Substitution treatments provided in prisons are not included in this database. Currently, there are big regional differences concerning the administration: in the Flemish Community, substitution treatment is often prescribed by specialised centres whereas in the French Community, general practitioners are more involved. A daily delivery of the treatment can be arranged in specialised centres or alternatively, in a pharmacy under the supervision of a pharmacist. In 2013 there were 17,482 persons registered in the Pharmanet register (see Table 5.6). Among them, only 13.5% were in treatment with buprenorphine. The patients were mainly men (77.0%) and had a mean age of 39.3 years. Methadone and buprenorphine are more often prescribed in the French Community (2/3 when counted together) than in the Flemish Community (1/3). Table 5.6 Characteristics of patients receiving methadone or buprenorphine in 2013 by type of substance Methadone Buprenorphine Total Total amount (N) 15,112 2,370 17,482 Women (%) Mean age Region (%) Source: NIHDI, 2014 Flemish Brussels-capital Walloon Dual diagnosis patients Over the past few years clinicians have noted increasing numbers of patients subjected to dual diagnosis (De Hert et al., 2010). Such patients are particularly vulnerable and currently lack any form of provision. Therefore, a pilot project was launched in 2002, setting up two specific units (one in the Flemish region and one in the Walloon region) (Sabbe et al., 2008). These units provide intensive and integrated treatment for both problems (drug use and mental disorders).

15 The aim is to stabilise patients after a period of intensive treatment to then refer them to other services to continue treatment Crisis and case management Emergency departments play an important role in offering first aid to persons with substance use-related disorders. These facilities inform patients on the treatment options and refer them to specialised treatment. They increase motivation for treatment and changing their behaviour. In Belgium, crisis care can be situated within two projects. First, a national pilot project exists for the crisis and case management of patients with substance use-related disorders (8 centres in Belgium offer four crisis beds with a maximum stay of five days). Second, the so-called Crisis Intervention Centres (CICs) (also described in chapter 7) intervene in crisis situations and arrange quick admission or support. On the other hand, they assist in physical detoxification and motivate to continue treatment. An important supportive strategy that may facilitate crisis management for persons with substance use-related disorders is case management. Case management has been implemented in Belgian substance abuse treatment since It has been institutionalized as part of the federal pilot project Crisis and case management for persons with substance use disorders. However, little is known about the effectiveness of this intervention, nor is there consistency concerning its application (Bruffaerts et al., 2010) QUALITY ASSURANCE OF DRUG TREATMENT SERVICES Different legal documents or conventions are available, describing the type of treatment or the type of functioning that should be applied in centres dealing with patients with a substance-related use problem: All low-threshold agencies (MSCC) have signed a convention with the NIDHI precisely describing the expected medical or social activities and the way their organization is to be arranged. For the other residential or ambulant centres with this type of convention, the document describes specific objectives for each facility. In this way, a diverse panel of therapeutic solutions is made available. Centres in the Walloon region that request funding for specialised addiction treatment activities, need to fulfil the missions and the functioning stated in the regional decree of 30 April For the French-speaking centres in Brussels, a decree (B.S./M.B ) describes directions for all ambulatory services working on social action and amongst them the drug addiction facilities. Centres for Mental Health in the Flemish region recognized by the Agency for Care and Health have additional rules to respect on quality of care and organization to get the agreement. 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY 85

16 3. TRENDS Currently, trends in treatment offer and demand are only studied based on the TDI data registered by the specialised centres that participate in a convention with the NIHDI. These centres are indeed obliged to complete this registration since 2011, while this is not yet the case for the other types of centres. These centres represent around 70% of the TDI registrations for 2013 for treatment demands for illicit drugs (10 out of the 34 day centres, 9 out of the 9 lowthreshold centres, 8 out of the 8 crisis centres and 15 out of the 15 long-term residential centres). 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY 86 Since 2011, a decrease is observed in the number of clients entering treatment for opiates. At the same time, there has been an increase for clients in treatment for cannabis, cocaine and stimulants. In 2013, cannabis is the main substance for entering treatment. (see Figure 5.2). This trend is due to a shift in the group of new patients (see Figure 5.3). Indeed, when looking at the trends concerning the primary drug used among people entering treatment for the first time a steep increase in cannabis patients and a decrease in opiates patients are noticed. This decrease of the proportion of treatment demand of opiates as primary drug is also notable in all European countries (EMCDDA, 2014). Concerning cannabis, the increased proportion is also partially explained by a high(er) proportion of judicial referral for treatment. Figure 5.2 Trends in numbers of clients entering treatment for the first time, by primary drug in the centres with a convention with the National Institute for Health and Disability Insurance between 2011 and 2013 Number of clients entering treatment 1,200 1, Opiates Cocaine Stimulants Hypnotics Cannabis Source: BTDIR, 2014

17 Figure 5.3 Trends in number of all clients entering treatment, by primary drug in the centres with a convention with the National Institute for Health and Disability Insurance between 2011 and 2013 Number of clients entering treatment 2,500 2,000 1,500 1, Opiates Cocaine Stimulants Hypnotics Cannabis 0 Source: BTDIR, Figure 5.4 Trends in number of clients receiving methadone or buprenorphine between 2009 and 2013 Number of clients 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2, Total Methadone Buprenorphine 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY 87 Source: NIHDI, 2014

18 4. NEW DEVELOPMENTS 4.1. CANNABIS USE DISORDER IN TROUBLED YOUTH THE INCANT PROJECT The INCANT trial was performed in 5 European cities (Berlin, Brussels, Paris, Geneva, The Hague) and included a comparison of Multidimensional Family therapy (MDFT) with individual therapy among 450 youngsters aged 13 up to 18 showing problematic patterns of cannabis use. The project followed the adolescents and their relatives for 12 months to determine both information about mental and behavioural characteristics (Rigter and Dekker, 2014). 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY 88 There is a strong belief among a selection of therapists in Western Europe that forced treatment of teenagers will harm the chances of the therapist to establish a therapeutic alliance with the adolescent and consequently influences the outcome of the treatment. Data from the study however contradict this notion: adolescents coerced into treatment accepted therapy and remained in therapy as long as other teens (Rowe et al., 2013). Yet, Schaub and colleagues demonstrated that both MDFT and individual treatment reduce the rate of externalising and internalising symptoms and in addition did improve family functioning. However, MDFT proved to be more efficient in decreasing externalising symptoms, especially in coerced adolescents (Schaub et al., 2014) HEROIN-ASSISTED TREATMENT THE TADAM PROJECT The pilot-project on assisted treatment with diacetylmorphine (TADAM) aimed at comparing the efficacy and feasibility of this treatment with regular approach of methadone treatment. To this order, 36 people in the experimental group and 38 in the control group were observed for one year. The project was finished in 2012 and conclusions were delivered in terms of efficacy of the treatment, socio-economic aspects, criminological aspects and patient satisfaction. The difference in efficacy between the two groups was significant at 3, 6 and 9 months but no longer significant after 12 months. This could be a false negative effect due to experimental conditions (patients of the experimental group knew that the treatment ended after 12 months). The treatment via diacetylmorphine showed less efficacy in socio-economic aspects than the methadone treatment. Due to limited observation time, the study under-evaluate the amount of positive impacts on society. The diacetylmorphine treatment could reduce delinquency of severe addicted persons. The treatment with diacetylmorphine met the expected help better than the methadone

19 treatment. In conclusion, the extension of diacetylmorphine treatment for people who continue to use street heroin despite treatment with methadone was recommended. This treatment should remain a second-line treatment, only available to patients refractory to methadone. For these patients, treatment with diacetylmorphine has proved to be more effective, but only if its length is not arbitrarily restricted. Recommendations were made on the conditions for the installation of such a centre, the inclusion criteria of the patients, the treatment organization, the infrastructure of the building and the staff (Demaret et al., 2013) ANALYSIS AND OPTIMIZATION OF SUBSTITUTION TREATMENT THE SUBANOP PROJECT Although substitution treatment has been applied on a large scale for over 15 years now, research on this topic remains limited. In order to gain more insight and optimize current practices of OST in Belgium, the SUBANOP study was set up. There s a need of a centralized and comprehensive database that allows the mapping of providers of OST as well as the follow-up on evolutions in treatment demand and practice. The combination of treatment-related data (e.g. dosage, type of medication and treatment regimen) with client data (e.g. characteristics, support needs and benefits from treatments) provides valuable information regarding a personalised approach in the allocation of treatment options. Additional research is advised regarding the nature and type of psychosocial support that is required for opiate dependent persons (Vander Laenen et al., 2013). 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY 89

20 5. CONCLUSIONS In Belgium, different institutional partners are in charge of the treatment for addictions which is coordinated by the General Drugs Policy Cell. A large variety of treatment facilities are available in the country providing ambulatory (including low-threshold) or residential services. In 2013, more than 9,000 patients entering treatment were registered by over 100 centres, mainly in outpatient services. Opiates and cannabis represent the main type of substance for a large majority of the patients entering treatment. However, these two groups of patients are very different in terms of age (older people in treatment for opiate use), sex (less women in treatment for cannabis) and high-risk drug use profile (less ever-injecting drug use for people in treatment for cannabis). 5. D R U G - R E L AT E D T R E AT M E N T: T R E AT M E N T D E M A N D A N D T R E AT M E N T AVA I L A B I L I TY 90 Moreover, a clear evolution is observed in the number of people entering treatment by primary drug. The number of treatment demand for opiates is declining and the number of treatment demand for cannabis is increasing. The latter, however, is partly due to the increased number of treatments referred by justice. The number of people receiving methadone or buprenorphine remains relatively stable over time and is more often prescribed in the French Community in comparison with the Flemish Community. Buprenorphine remains less often prescribed. Several studies were conducted on specific aspects of treatment to work towards potential developments in treatment. A remarkable pilot study on assisted treatment with diacetylmorphine concluded that treatment with diacetylmorphine is only more effective than the methadone treatment for a specific target group: assisted treatment with diacetylmorphine is recommended for people who continue to use street heroin despite the treatment with methadone. Recommendations were made on the main aspects (target group, infrastructure, rules, ) for the development of a similar new project. Nevertheless, there are currently no further plans on implementing these results. Acknowledgements We would like to thank Mr Hogge (Ph.D.), Mr Verstuyf, Mrs Huard, Prof. dr. Broeckaert, Prof. dr. Dom, Prof. dr. Pelc and Prof. dr. Soyez for their contribution of the data collection and their valuable feedback. Their essential involvement is gratefully acknowledged.

21 BIBLIOGRAPHY Anderson, P., Møller, L., & Galea, G., Alcohol in the European Union, consuption, harm and policy approaches, Denmark: WHO Regional Office for Europe. ASL, Präventionsmaterial. [Online] Arbeitsgemeinschaft für suchtvorbeugung und lebenbewältigung (ASL). Available at: < [Accessed ]. ASL, Tätigkeitsbericht 2013 Arbeitsgemeinschaft für Suchtvorbeugung und Lebensbewältung, Eupen: ASL. Backmund, M., Meyer, K., Von, Z.M., & Eichenlaub, D., Treatment of hepatitis C infection in injection drug users. Hepatology, 34,(1), pp Baeten, I., Bernaert, I., Claessens, J., De Paepe, N., & Raskin, K., Individueel screeningsinstrumentervaringen met middelengebruik voor jongeren, Brussel: VAD. Baeten, I., Bernaert, I., De Paepe, N., and Degryse, B., Crush: werken met jongeren rond relaties, alcohol en cannabis. [Online] VAD. Available at: < crush_a4_printversie.pdf> [Accessed ]. Bekkering, GE., Aertgeerts, B., Asueta-Lorente, J.-F., Autrique, M., Goossens, M., Smets, K., van Bussel, J.C.H., Vanderplasschen, W., Van Royen, P., Hannes, K., & for the ADAPTE-youth project group, Practitioner review: Evidence-based practice guidelines on alcohol and drug misuse among adolescents: a systematic review. Journal of Child Psychology and Psychiatry, 55,(1), pp Belgian Research Aids&HIV Consortium, HIV-Plan [Online] Belgian Research Aids&HIV Consortium. Available at: < NationalPlanDutch.pdf> [Accessed ]. Blanckaert, P., Van Amsterdam, J., Brunt, T., Van den Berg, J., Van Durme, F., Maudens, K., & Van Bussel, J., Méthylamphétamine: a health threat for recreational amphétamine users. Journal of Psychopharmacology, 27,(9), pp Bohnert, A.S.B., Tracy, M., & Galea, S., Characteristics of drug users who witness many overdoses: Implications for overdose prevention. Drug and Alcohol Dependence, 120,(1-3), pp Bollaerts, K., Aerts, M., & Sasse, A., Improved benchmark-multiplier method to estimate the prevalence of ever-injecting drug use in Belgium, Archives of Public Health, 71,(1), pp.10. Bruffaerts, R., Vanderplasschen, W., Van Hal, G., & Demyttenaere, K., Crisisopvang voor middelengebruikers in België: een formele evaluatie en aanbevelingen voor een duurzaam beleid - De Evaluatie van Crisis en Case Management (ECCAM) - studie Burssens, D., Bemiddeling in strafzaken. Een blik op de praktijk vanuit SIPAR, de databank van de justitiehuizen. Panopticon Libri, 2012,(5), pp Centre bruxellois de promotion de la santé, Evaluation du label quality nights auprès du public en Région de Bruxelles-Capitale, Bruxelles : Eurotox. Cid, J., Is imprisonment criminogenic? A comparative study of recidivism rates between prison and suspended prison sanctions. European Journal of Criminology, 6,(6), pp College van procureurs-generaal, Jaarstatistiek van het Openbaar Ministerie. Opsporing en vervolging van strafzaken door de parketten van de rechtbanken van eerste aanleg. [Online] Gegevensbank van het College van procureurs-generaal: Statistisch analisten. Available at: < [Accessed ]. BIBLIOGRAPHY 173

22 BIBLIOGRAPHY 174 Colman, C, De Ruyver, B., Vander Laenen, F., Vanderplasschen, W., Broekaert, E., De Keulenaer, S., and Thomaes, S., De drugbehandelingskamer: een andere manier van afhandelen. Het proefproject geëvalueerd. Antwepren: Maklu. Commission of the European Union EU Drugs Strategy p.9 C402/ Cornelis, E., Persuasive effects of two-sided social marketing messages, Leuven: KULeuven. Cornish, R., Strang, J., Vickerman, P., & Hickman, M., Risk of death during and after opiate substitution treatment in primary care: prospective observational study in UK General Practice Research Database. British Medical Journal, 2010,(341), pp.c5475. CPAS de la ville de Bruxelles, Le service d accompagnement psychosocial. [Online] Available at: < [Accessed ]. Crawford, S. & Bath, N., Peer support models for people with history of injecting drug use undertaking assessment and treatment for hepatitis C virus infection. Clinical infectious diseases, 57,(S2), pp.s75-9. De Boyser, K., Linchet, S., Van Dijck, L., Casman, M. T., Dierckx, D., & Vranken, J., Onderzoek naar de OCMW-hulpverlening van dak- en thuislozen., Brussel: POD Maatschappelijke integratie. De druglijn, Aan de slag. [Online] VAD. Available at: < aspx> [Accessed ]. De druglijn, Student zijn en cannabis. [Online] VAD. Available at: < omgaan-met-drugs/studenten/student-zijn--cannabis.aspx> [Accessed ]. De Hert, M., Roos, K., Gillain, B., Detraux, J., Sweers, K., van Werde, D., & Peuskens, J., Dual diagnosis among schizophrenic patients in Belgian psychiatric services: Prevalence and available treatment. Acta Psychiatrica Belgica, 110,(2), pp De Keulenaer, S. & Thomaes, S., 2013, De uitkomst van de Gentse drugbehandelingskamer rond recidive, In Het pilootproject drugbehandelingskamer te Gent: een uitkomstenevaluatie, F. V. W. Vander Laenen et al., eds., Gent: Academia Press, pp De Kiem, Residentieel - Programma-aanbod. [Online] Available at: < index.php/residentieel> [Accessed ]. De Ruyver, B., Colman, C., & Vandam, L., Drugs en criminaliteit: bestaat het ene zonder het andere? De orde van de dag, 2008,(44), pp De Ruyver, B., Ponsaers, P., Lemaître, A., Macquet, C., De Wree, E., Hodeige, R., Pieters, T., Cammaert, F., & Sohier, C., Effecten van alternatieve afhandeling voor druggebruikers, Gent: Academia press. De Ruyver, B., Vander Laneen, F., & Eelen, S., 2012, The long road to an integral and integrated policy in Belgium, In Reflections on the concept of coherence for a policy on psychoactive substances and beyond, R. Muscat, B. Pike, & & members of the Coherent Policy Expert Group, eds., Strassbourg: Council of Europe Publishing. De Wree, E., De Ruyver, B., Verpoest, K., & Colman, C., All in favour? attitudes of stakeholders and drug users towards judicial alternatives. European Journal on criminal policy and research, 14,(2008), pp De Wree, E., Pauwels, L., Colman, C., & De Ruyver, B., Alternative sanctions for drug us: fruitless efforts or miracle solution? Crime, Law and Social change, 52,(2009), pp Decorte, T. & D Huyvetter, E Lokale detailhandel in drugs in Antwerpen. Een exploratief onderzoek, drugmonitor Antwerpen, Stedelijk Overleg Drugs Antwerpen.

23 Decorte, T. & D Huyvetter, E Lokale detailhandel in drugs in Antwerpen. Een exploratief onderzoek, drugmonitor Antwerpen, Stedelijk Overleg Drugs Antwerpen. Decorte, T. & Paoli, L., Cannabis production in Belgium. Assessment of the nature and harms, and implications for priority setting (CANMARKT) Summary, Brussels: Belgian science policy. Decorte, T., Cannabis social clubs in Belgium: Organizational strengths and weaknesses, and threats to the model. International Journal of Drug Policy(0), Decorte, T., Mortelmans, D., Tieberghien, J., & De Moor, S Haalbaarheid van een repetitieve prevalentiestudie onder de algemene bevolking. Gent. Decorte, T., Muys, M., & Slock, S Cannabis in Vlaanderen. Patronen van cannabisgebruik bij ervaren gebruikers. Leuven: Acco. Decorte, T., Stoffels, I., Leuridan, E., Van Damme P., & Van Hal, G., Middelengebruik onder sekswerkers in België: een kwantitatieve en kwalitatieve studie in vijf sectoren van de seksindustrie., Gent: Academia Press. Defillet, T., Juridische handvatten beroepsgeheim voor hulpverleners., Brussel: VAD. Degenhardt, L., Larney, s., Randall, D., Burns, L., & Hall, W., Causes of death in a cohort treated for opioid dependence between 1985 and Addiction, 109,(1), pp Demarest, S., Tafforeau, J., Van Oyen, H., & et al., Health Interview Survey 2001: Protocol for the sampling design, Brussels: Scientific Institute of Public Health. Demarest, S., Van der Heyden, J., Charafeddine, R., Tafforeau, J., Van Oyen, H., & Van Hal, G., Socio-economic differences in participation of households in a Belgian national health survey. European Journal of Public Health, 23,(6), pp Demaret, I., Litran, G., Magoga, C., Deblire, C., De Roubaix, J., Quertemont, E., Van Caillie, D., Dubois, N., Lemaître, A., & Ansseau, M., Projet TADAM - Rapport final , Liège : Université de Liège. Deprez, N., Antoine, J., Asueta-Lorente, J. F., Bollaerts, K., Van der Linden, T., & Van Bussel, J., Belgian national report on drugs 2011, new developments, trends and in-depth information on selected issues, Brussels: Scientific Institute of Public Health. Devos, A., 2009, Balans van het tienjarig bestaan van de justitiehuizen en perspectieven voor de komende jaren, In 10 jaar justitiehuizen: balans en perspectieven, A. Devos, ed., Brussel: Federale overheidsdienst Justitie, pp Dienst voor strafrechtelijk beleid, Dienst voor strafrechtelijk beleid: statistiek. [Online] Available at: < [Accessed ]. Edmonds, K., Sumnall, H., McVeigh, J., & Bellis, M. A., Drug prevention among vulnerable young people, Liverpool, UK: National Collaborating Centre for Drug Prevention. EMCDDA, 2003, Social exclusion and reintegration, In Annual report on the state of the drug problem in the European Union and Norway, pp EMCDDA, Trends in injecting drug use in Europe. Selected issue 2010, Luxembourg, Publication office of the European union: EMCDDA. EMCDDA, European Drug Report. Trends and developments, 2014, Luxembourg: Publications Office of the European Union. EMCDDA, European Drug Report. Trends and developments. 2014, Luxembourg: Publications Office of the European Union. BIBLIOGRAPHY 175

24 BIBLIOGRAPHY 176 Espace P, Espace P... vers une société prostitution admise. [Online] Available at: < espacep.be/> [Accessed ]. Evenepoel, T., Jaarverslag 2013 van de druglijn. [Online] VAD. Available at: < druglijn.be/media/17359/jaarverslag_dl_2013.pdf> [Accessed ]. Favresse, D. & de Smet, P Tabac, alcool, drogues et multimédias chez les jeunes en Communauté francaise, résultats de l enquête HBSC Bruxelles, ULB-SIPES. Federale Politie - CGOP / Beleidsgegevens, Politionele criminaliteitsstatistieken, Belgie, [Online] Available at: < nationaal/rapport_2013_trim4_nat_belgie_nl.pdf> [Accessed ]. Fédito Bruxelles, FEIAT, and CLDB, Mémorandum. [Online] Fédito Bruxelles ; FEIAT ; CLDB. Available at: < =651797aad04635f3-842BB75C-045B-144E-E142D5807E3B7937&jsessionid=843036bad2186ed20 c8d a1b4c> [Accessed ]. Ferri, M., Allara, E., Bo, A. G. A., & Faggiano, F., Media campaigns for the prevention of illicit drug use in young people, London: The cochrane collaboration. Fountain, J., Hartnoll, R., Olszewski, D., and Vicente, J., Understanding and responding to drug use: the role of qualitative research. Belgium : Office for Official Publications of the European Communities. FPS Economy, Statistics Belgium (be.stat). [Online] Available at: < statistiques/webinterface/bestat_home/> [Accessed ]. FPS Justitie, Bemiddeling in strafzaken. [Online] FOD Justitie. Available at: < belgium.be/nl/binaries/bemiddelingstrafzakennl_tcm pdf> [Accessed ]. FPS Justitie., Substitutie in de gevangenissen. Free Clinic, Activering harde kern druggebruikers Atheneumbuurt. [Online] Available at: < [Accessed ]. Free Clinic, Buro Aktief - Sociale activering door samen korte opdrachten uit te voeren. [Online] Available at: < [Accessed ]. Freiburger, T.L. & Iannacchione, B.M., An examination of the effect of imprisonment on recidivism. Criminal justice studies, 24,(4), pp Gisle, L., 2010, Het gebruik van illegale drugs, In Gezondheidsenquête België, Rapport II - Leefstijl en Preventie, vol L. Gisle et al., eds., Brussel: Operationele Directie Volksgezondheid en surveillance - Wetenschappelijk Instituut Volksgezondheid, pp Gisle, L., 2010, L usage des drogues illicites, In Enquête de santé, Rapport II - Style de Vie et Prévention, vol L. Gisle et al., eds., Bruxelles : Direction Opérationnelle Santé publique et surveillance. Institut Scientifique de Santé Publique, pp Godin, I., Decant, P., de Smet, P., Favresse, D., & Moreau, N., Heatlh behaviour in School-Aged Children Lifetime, last 12 months and last 30 days prevalence tables., Brussels: ULB. Godin, I., Decant, P., Moreau, N., de Smet, P., & Boutsen, M La santé des jeunes en en Communauté française de Belgique, résultats de l enquête HBSC Bruxelles, ULB-SIPES. Goessens, M., Rapport d activité asbl Transit

25 Hannes, K, van Bussel, J. C. H., Aertgeerts, B., Vanderplasschen, W., Van Royen, P., and Geirnaert, M., Adapting best practice guidelines for the detection, prevention and treatment of substance abuse in children and youngsters to a local Belgian context (ADAPT_YOUTH). [Online] Belgian Science Policy. Available at: < [Accessed ]. Hannes, K., van Bussel, J. C. H., Aertgeerts, B., Vanderplasschen, W., Van Roypen, P, and Geirnaert, M., Adapting best practice guidelines for prevention, screening and treatment of substance misuse in adolescents to the Belgian context (ADAPTE-youth), Final unpublished report. Hardy, T. & Snowden, M., Family impact of imprisonment and the community specialist practitioner. Community practitioner, 83,(10), pp Hels, T., Lyckegaard, A., Simonsen, K.W., Steentoft, A., & Bernhoft, I.M., Risk of severe driver injury by driving with psychoactive substances. Accident analysis and prevention, 59,(2013), pp Henkel, D., Unemployment and Substance Use: a review of the literature ( ). Current Drug Abuse Reviews, 4, pp Hogge, M. & Denoiseux, D., L usage de drogues en Fédération Wallonie-Bruxelles. Rapport Eurotox ASBL. Housing First Belgium, Mise en place de l expérimentation Housing First Belgium. Septembre Février 2014 Houwing, S., Legrand, S.A., Mathijssen, R., Hagenzieker, M., Verstraete, A.G., & Brookhuis, K., Prevalence of psychoactive substances in dutch and belgian traffic. Journal of studies on alcohol or drugs, 73,(6), pp Hublet, A., De Bacquer, D., Valimaa, R., Godeau, E., Schmid, H., Rahav, G., & Maes, L., Smoking trends among adolescents from 1990 to 2002 in ten European countries and Canada. BMC.Public Health, 6, pp.280. Interministeriële Conferentie Drugs, Een global en geïntegreerd drugsbeleid voor België. Gemeenschappelijke verklaring van de interministeriële Conferentie Drugs. [Online] Available at: < Drugs/ #.VDKQq_mSyQs> [Accessed ]. Jackson, L.A., McWilliams, S., Martin, F., Dingwell, J., Dykeman, M., Gahagan, J., & Karabanow, J., Key challenges in providing services to people who use drugs: The perspectives of people working in emergency departments and shelters in Atlantic Canada. Drugs: Education, Prevention and Policy, 21,(3), pp James, R. K., Gilliland, B. E., and James, L., Crisis intervention strategies. Belmont: Brooks/Cole, Cengage Learning. Kinable, H., VAD-leerlingenbevraging in het kader van een drugbeleid op school. Syntheserapport schooljaar , Brussels: VAD. Kinable, H., VAD-leerlingenbevraging in het kader van een drugbeleid op school. Syntheserapport schooljaar , Brussels: VAD. La Trace asbl, Centre d accueil et d accompagnement psycho-social par le sport-aventure. [Online] Available at: < [Accessed ]. Lambrecht, P. & Andries, C., Het Vlaamse Schoolonderzoeksproject naar alcohol en andere drugs - VLASPAD EMCDDA ST2, Brussels: VUB. BIBLIOGRAPHY 177

26 BIBLIOGRAPHY 178 Lambrecht, P., Andries, C., Engels, T., Senterre, C., Piette, D., & De Smedt, P., ESPAD03: Outline for Belgian Report 2. Results Belgium 2003., Brussel: Vrije Universiteit Brussel. Larimer, M.E., Malone, D.K., Garner, M.D., Atkins, D.C., Burlingham, B., Lonczak, H.S., Tanzer, K., Ginzler, J., Clifasefi, S.L., Hobson, W.G., & Marlatt, G.A., Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. Journal of the American Medical Association, 301,(13), pp Larmuseau, C., Moens, O., Steenhuyzen, S., Bernaert, I., and Lambrechts, M-C., Verslag van de indicatoren meting 2012 van het gezondheidsbeleid in Vlaamse scholen. [Online] Vlaams instituut voor gezondheidspromotie en ziektepreventie. Available at: < enbank/32e75b2e2f0f28d2d876cad6f295f083.pdf> [Accessed ]. Laudens, F., Drugpreventie bij jongeren uit etnisch-culturele minderheden. Draaiboek voor het uitvoeren van een lokale verkenning en het opzetten van preventieve acties. [Online] VAD. Available at: < Le Projet Lama asbl, Présentation générale. [Online] Available at: < [Accessed ]. Legrand, S.A., Isalberti, C., Van der Linden, T., Bernhoft, I.M., Hels, T., Simonsen, K.W., Favretto, D., Caplinskiene, M., Ferrarra, S.D., Minkuviene, Z., Pauliukevicius, A., Houwing, S., Lillsunde, P., Langel, K., Blencowe, T., & Verstraete, A.G., Alcohol and drugs in seriously injured drivers in six European countries. Drug testing and analysis, 5,(3), pp Lewis, S. & Roberts R., A., Crisis assessment tools: the good, the bad and the available. Brief treatment and crisis intervention, 2001,(1), pp Liebling, A. & Arnold, H., Social relationships between prisoners in a maximum security prison: violence, faith and the declining nature of trust. Jounral of criminal justice, 40,(2012), pp Lievens, D., Vander Laenen, F., & Christiaens, J., Public spending for illegal drug and alcohol treatment in hospitals: an EU cross-country comparison. Substance Abuse Traetment, Prevention, and Policy, 9,(26), Livingston, J., Milne, T., Lan Fang, M., & Amari, E., The effectiveness of interventions for reducing stigma related to substance use disorders: a systematic review. Addiction, 107,(1), pp Lombaert, G., Middelengebruik bij 12 tot 18-jarige scholieren in Brugge, Gent: De Sleutel. Luisetto, S. and Hensgens, P., Mémorandum de la Fédito Walonne. [Online] Fédito Walonne. Available at: < pdf> [Accessed ]. Lurigio, A.J., Drug treatment availability and effectiveness: Studies of the general and criminal justice population. Criminal justice and behavior, 27,(4), pp Macarthur, G., van Velzen, E., Palmateer, N., Kimber, J., Pharris, A., Hope, V., Taylor, A., Roy, K., Aspinall, E., Goldberg, D., Rhodes, T., Hedrich, D., Salminen, M., Hickmann, M., & Hutchinson, S., Interventions to prevent HIV and Hepatitis C in people who inject drugs: a review of reviews to assess evidence of effectiveness. International Journal of Drug Policy, 25,(1), pp McCabe, S.E., Boyd, C.J., Cranford, J.A., Morales, M., & Slayden, J., A modified version of the Drug Abuse Screening Test among undergraduate students. J.Subst.Abuse Treat., 31,(3), pp McCambridge, Hawkins, B., & Holden, C., Vested interests in addiction research and policy. The challenge corporate lobbying poses to reducing society s alcohol problems: insights from UK evidence on minimum unité pricing. Addiction, 109,(2), pp